Provider Demographics
NPI:1205269073
Name:FOR ALL AGES DENTAL ASSOCIATES
Entity type:Organization
Organization Name:FOR ALL AGES DENTAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROULA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-905-4395
Mailing Address - Street 1:478 TORREY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4696
Mailing Address - Country:US
Mailing Address - Phone:508-586-1800
Mailing Address - Fax:
Practice Address - Street 1:478 TORREY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4696
Practice Address - Country:US
Practice Address - Phone:508-586-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN21173261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental